Germany outsources elder care

It costs too much to take care of the western world’s old and frail in their own homes or care homes. German is beginning to export the work to low-wage service economies.

by Heike Haarhoff

Mrs T, who is 87 and a widow, lives in a big house in Berlin that her husband built for the children they intended to have but never did. Her only family is a niece who lives 700km away and a distant relative in the US. Her voice is hoarse because she doesn’t get to talk often, she is unsteady on her feet and she can’t remember the way to the doctor’s surgery: he has diagnosed her with progressive senile dementia.

Mrs T is sure of one thing: she will not move to a retirement home, a view shared with two thirds of Germans, if opinion polls are correct. Their views have been confirmed by media reports of staff hastily fitting gastric tubes to residents because there were no carers to feed them, and not changing incontinence pads for hours. The Federal Association of Private Social Service Providers (BPA) estimates a current shortfall of 30,000 nurses, perhaps 220,000 by 2020. Not enough qualified staff, difficult working conditions (staff are overstretched in upmarket retirement homes too), and a worse shortage in the home care sector.

Norbert Blüm, social affairs minister in Helmut Kohl’s “black and yellow” coalition government (1) did introduce compulsory long-term care insurance in 1995, with employers and employees contributing equally. It was never designed to cover all risks though, because it was tacitly believed that Germans would not live long enough to become dependent, or that their families would look after them. Angela Merkel’s government continues to count on private care, but family arrangements have limits: grown children rarely live in the same area as their parents, and female relatives (wives, daughters and daughters in-law), who used to looked after the elderly at home at minimal cost, are not as available as they once were.

Retirement home residents pay between €1,000 and €3,000 a month, plus board and lodging, on top of their insurance payments. The state will intervene if they do not have the means (and a survey by the Federal Statistical Office this year found 400,000 Germans did not), but it examines an applicant’s situation in detail. It decided Mrs T’s home should be sold to jointly finance her care home costs, but this might not be enough (or be appreciated by her heirs).

A less expensive solution

Her niece is looking for a less expensive solution. She could employ a home care nurse from eastern Europe, taking advantage of outpatient services provided as a non-cash benefit of her long-term care insurance (up to €700 a month), and provide some family help. Many Germans favour this, but Mrs T needs round-the-clock care, which she can’t afford. Her niece is discreetly looking into an option that the German tabloids have recently denounced as “offshoring granny and granddad”, unworthy of a country with Christian values: sending Mrs T abroad. The Czech Republic and Thailand both offer such services, and the niece thinks Thailand might have a more suitable climate, as her aunt is always cold: “Yes, it would still be a retirement home, but one with more staff, more human warmth and attention, and women who would sleep on a mat next to my aunt at night and wake up next to her in the morning, who would take care of her with affection and would listen to her. What difference does it make if she is 700 or 7,000 kilometres away? We wouldn’t see her often in either case.”

Swiss social worker Martin Woodtli tells his own story on the net — he took his mother, suffering from Alzheimer’s, to Thailand where he was working. The story is publicity for his programme of exotic care led by a German-speaking team. “I am convinced we need to find new ways to care for people, so we can meet the needs of both people suffering from senile dementia, and their loved ones.” Woodtli and his Thai team offer “24-hour care with private nurses” for dementia sufferers to live out their old age in a “pleasant and welcoming environment”. Three carers take turns looking after one dependent person exclusively. The entire package usually costs “less than half the cost of a retirement home in Germany or Switzerland,” according to the team supervisor.

To grow old with dignity

Similar deals are available in eastern Europe, and more are being developed: Over 7,000 Germans live in retirement homes in Hungary, 3,000 in the Czech Republic, and 600 in Slovakia. There are no figures for Greece, Spain, Ukraine, Thailand and the Philippines, which are reputed to be the principal destinations (2). “I do consider it an option,” says Mrs T’s niece. “Given the traditions of Thai society, I would hope that my aunt could grow old with dignity.”

Politicians of all parties denounce the practice as cynical and heartless. Christoph Fuchs, a geriatrician in Munich, points out that according to the UN convention on the rights of people with disabilities, “dementia doesn’t require supplementary medicine, but greater human contact.” How do you grow old with dignity without it costing too much? That is the dilemma Merkel’s coalition has not managed to solve. Politicians have put the issue on the back burner. Although the coalition pompously declared 2011 “the year of Dependency”, it passed without any significant decision. Germany is ageing; the number of dependent people has reached 2.5m, and could double by 2050.

“We need a new social contract,” says Jürgen Gohde, director of the German Foundation for the Care of the Elderly. Autonomy, participation, respect and dignity are basic social rights, not extreme demands.

He says there is currently little support for the 1.5 million people who look after relatives at home and a shortage of around 2.5m homes adapted to older people, and few favourable environments where people with dementia can live independently for as long as possible, with grocers, doctors and hairdressers close by. If nothing changes, Mrs T will soon leave her little street in north Berlin and end her days far away.